Frequently Asked Questions
Where is your health insurance coming from?
It’s important to know who provides your coverage and where to go if you have questions. The following are the three most common sources of health insurance:
Employer: If you work for a company that has 50 or more full-time employees, they must offer health insurance to full-time employees.
Employer-based plans are referred to as group or workplace health coverage, and it is a policy that is purchased by an employer and offered to the eligible employees as a benefit.
One of the major benefits of a group plan is that most employers (but not all) make a contribution toward the cost of your premium. Therefore, employer-based plans are most often (but not always) the cheapest option.
Marketplace: The Marketplace was created by the ACA to help people shop for health insurance. The federal government operates a number of Marketplaces, which you can access at HealthCare.gov. However, some states run their own Marketplaces, so you would have to shop at your specific state Marketplace.
Those who do not have access to employer-based plans and whose income level is such that it would qualify them for subsidies would be ideal customers for the Marketplace exchange.
The Marketplace provides health plan shopping and enrollment through the website, call centers and in-person help.
Individual Plans: Just like most other insurance products, you can purchase an individual health plan from the best health insurance companies, broker or through the Marketplace. If you are shopping on your own, make sure you have a complete understanding of the policy, if you have questions, get them answered before signing on the dotted line. If your income does not qualify you for subsidies, and you do not have access to employer-based health insurance, then you might
have better luck shopping with individual health care providers.
What is covered by your health insurance plan?
Outpatient Care: This is the type of care you receive without being admitted to the
hospital. Checkups, doctor visits and even some surgeries that allow you to go home on the same day would be considered outpatient procedures.
Emergency Room Visits: If you are in an accident you may need to go to the emergency room. Your insurance company will cover this cost but it is important to note that ER visits often come with very high copays.
Inpatient Care: This refers to medical services that require admission to the
hospital. You must be formally admitted to the hospital for health insurance to kick in and once again, deductibles, co-pays, and coinsurance costs can be high.
Pre and Post Natal Care: This includes prenatal and postnatal doctor visits, gestational diabetes screenings, as well as lab studies and medications. Inpatient services such as doctor fees and hospital bills are also covered. After the baby arrives, newborn care, lactation counseling and breast pump rental are also covered.
Mental Health and Substance Use Services: This includes behavioral health treatment, counseling and
Prescription Drugs: This will cover the cost of prescription drugs on your formulary
which you are prescribed. In almost all cases, there will be a copay.
Rehabilitation services and devices: Services such as physical and occupational therapy, speech language and psychiatric are all covered under this section of the policy.
Lab Tests: All doctor-ordered lab tests should also be covered. There will often be a co-pay for these services.
Preventive Services: Vaccines and screenings fall under this category. Vaccines for
children should always be free.
Pediatric Services (under 19 years of age): Care for your children should be covered, but many services will have a co-pay. This includes dental care and vision care for kids.
It is important to remember that coverage levels can vary between plans, and you will almost always be responsible for co-pays, co-insurance and deductibles.
Can I make changes to our plan?
If you are unhappy with your current plan, you can compare different plans at any time, however you can only enroll in a different plan two ways: during an open enrollment period or during a special enrollment period because of a qualifying event. For employer-based plans, your company will inform you of its open enrollment period when you are hired, and employers typically notify employees of upcoming open enrollment well in advance.
For the marketplace or individual plans, the open enrollment dates change each year.
What type of plans do you have?
There are a variety of plans available, whether you are choosing an individual plan, a Marketplace policy or a workplace plan. Knowing the difference between the various plans can help you select the right plan for you or your family.
Here is an overview of available options: